Fine-tuning the needle: analysis of acupuncturist response to alarming events during gynecological oncology surgery

OBJECTIVE

Examining an intra-operative acupuncture/acupressure setting, with real-time "fine-tuning" in response to alarming events (AEvs) during gynecological oncology surgery.

METHODS

Narratives of acupuncturists providing intraoperative acupuncture during gynecological oncology surgery were qualitatively analyzed. These described real time "fine-tuning" in response to AEvs during surgery, identified through hemodynamic changes (e.g., systolic/diastolic arterial pressure); bispectral index (BIS) elevation; and feedback from surgeons and anesthesiologists. Documentation of acupuncturist responses to AEvs was addressed as well.

RESULTS

Of the 48 patients in the cohort, 33 had at least one intraoperative AEv (69%), of which 30 were undergoing laparoscopic surgery and 18 laparotomies. A total of 77 AEvs were documented throughout surgery (range 1-7; mean: 2.3 events per patient), identified through increased (63 events) or decreased (8) mean arterial pressure (MAP); increased BIS levels (2), or other hemodynamic parameters (4). Integrative oncology interventions implemented in response to AEs included acupressure alone (59); combining acupressure with acupuncture (10); or acupuncture alone (4). In 54 (70%) events, documentation was provided from beginning to conclusion of the AEv, with a mean duration of 9.7 min, with 32 events including a documented anesthesiologist intervention.

CONCLUSION

The present study demonstrated the feasibility of intraoperative acupuncture with acupressure, with ongoing "fine-tuning" to AEvs identified through objective pain-related parameters (MAP, heart rate and BIS) and real-time input from surgeons and anesthesiologists. Documentation of the intraoperative IO practitioner's response to these AEvs is important, and should be addressed in future research of the innovative integrative model of care.

TRIAL REGISTRATION NUMBER

CMC-18-0037 (Carmel Medical Center, June 11, 2018).

Effect of known pathological risk factors on the incidence of metastatic lymph nodes and survival in early-stage vulvar cancer: SEER analysis

OBJECTIVE

The current study was performed to evaluate the incidence of positive lymph nodes (LNs) in relation to known pathological risk factors, specifically among patients with apparent low-grade, small tumors.

METHODS

We used the Surveillance, Epidemiology, and End Results (SEER) database to retrospectively identify patients with vulvar squamous cell carcinoma (SCC) diagnosed between January 1, 2000, and December 31, 2019, with known tumor size and regional LN examined. A comparison between patients who had positive and negative LNs was conducted to identify risk factors for LN metastases in relation to survival. Subgroup analysis was conducted in patients with diagnosed grade 1 vulvar SCC and tumor size up to 2 cm according to the status of LNs.

RESULTS

Multivariate analysis found that both grade of disease and tumor size were significant factors in predicting LN status. Among patients with low-grade small tumors up to 2 cm, the odds ratio for positive LNs was 2.5 for those with tumor size larger than 1 cm. In a multivariate survival analysis, older age, larger tumor size, and positive LNs were independently associated with decreased survival.

CONCLUSIONS

The current study confirms that among small tumors, those larger than 1 cm have a significantly increased risk for positive nodes compared with those smaller than 1 cm, and, among this specific group, patients with positive nodes have decreased survival. Future studies are needed to answer the question of whether, in the era of the sentinel node procedure, it is safe to omit LN evaluation altogether.

Attitude of BRCA1/2 mutation carriers towards surgical risk reduction for breast, ovarian and uterine cancer: still much to be done

OBJECTIVE

To study and quantify the attitude of BRCA1/2 mutation carriers towards surgical risk reduction procedures.

METHODS

This cross-sectional national study was conducted by distribution of an anonymous questionnaire on social media platforms and to BRCA1/2 carriers' medical clinic.

RESULTS

530 BRCA1/2 mutation carriers answered the survey. Risk reduction bilateral salpingo-oophorectomy was discussed with 447/489 (91%) of patients and performed in 260/489 (53%). Hormonal replacement therapy was discussed in 280/474 (59%) of patients. Addition of hysterectomy to risk reduction bilateral salpingo-oophorectomy was discussed in 129/481 (27%) of patients and performed in 44/443(10%). Age over 35 years at time of mutation detection was found to be significant in raising risk reduction bilateral salpingo-oophorectomy and hysterectomy performance rates. Risk reduction mastectomy was discussed in 390/471 (83%) of patients and performed in 156/471 (33%). In a multivariate analysis, BRCA1 mutation carriers (OR=1.66 (95% CI 1.07 to 2.57), p=0.024) and a personal cancer history leading to the mutation detection (OR=4.75 (95% CI 1.82 to 12.4), p=0.001) were found to be significant in increasing the likelihood of opting for risk reduction mastectomy. Additionally, highest risk reduction mastectomy performance rates were observed in the group of patients with a first-degree family history of breast cancer under the age of 50 years (OR=1.58 (95% CI 1.07 to 2.32), p=0.01).

CONCLUSIONS

This study highlights the high performance rates of risk reduction bilateral salpingo-oophorectomy, while hysterectomy was added in 10%, and that despite high awareness and acceptance rates for risk reduction mastectomy, only 33% had the procedure. The data presented provides insights for the clinician counseling BRCA1/2 mutation carriers, with regards to adherence to recommendations, understanding their concerns towards treatment and management alternatives; and finally, to construct a personalized management medical plan.

Sentinel lymph node sampling versus full lymphadenectomy in endometrial cancer: a SEER database analysis

OBJECTIVE

To assess the long term outcomes and prognosis of sentinel lymph node sampling compared with full lymph node dissection in endometrial cancer patients.

METHODS

We used the Surveillance, Epidemiology, and End Results (SEER) database for information on women diagnosed with endometrial cancer from 2010 to 2019. We conducted a comparison including overall survival between patients who had undergone sentinel lymph node sampling only and patients who had undergone formal lymph node dissection. Propensity score matching was performed according to the patient's age, type of endometrial cancer, grade and stage of disease, and adjuvant therapy. Subgroup analyses were performed according to type and grade of endometrial cancer.

RESULTS

41411 endometrial cancer patients were identified through the database. After matching, 6019 patients each were included in the sentinel lymph node and lymph node dissection groups. Median (interquartile range (IQR)) follow-up time was 16 (7-31) months in both groups. One year survival rates were longer in the sentinel lymph node group compared with the lymph node dissection group (hazard ratio (HR) 1.61 (95% confidence interval (CI) 1.17 to 2.21); p=0.004). Subgroups analysis according to grade of disease showed that 1 year survival rates were longer in the sentinel lymph node group in patients with endometrioid-type grade 1-2 endometrial cancer (HR 1.70 (95% CI 1.31 to 2.56); p=0.01), while no difference in survival was found between the sentinel lymph node and lymph node dissection groups in the subgroup of patients with high grade endometrial cancer (HR 1.40 (95%CI 0.94 to 2.24); p=0.17). In patients with low grade endometrial cancer included in the sentinel lymph node group, only 7% had lymph nodes positive for malignancy compared with 17% in the high grade group.

CONCLUSION

Survival rates were not compromised in endometrial cancer patients undergoing sentinel lymph node sampling versus full lymph node dissection for all grades of disease.

Gestational choriocarcinoma

Gestational choriocarcinoma accounts for 5% of gestational trophoblastic neoplasms. Approximately 50%, 25%, and 25% of gestational choriocarcinoma occur after molar pregnancies, term pregnancies, and other gestational events, respectively. The FIGO scoring system categorizes patients into low (score 0 to 6) and high risk (score 7 or more) choriocarcinoma. Single-agent and multi-agent chemotherapy are used in low- and high-risk patients, respectively. Chemotherapy for localized disease has a goal of eradication of disease without surgery and is associated with favorable prognosis and fertility preservation. Most patients with gestational choriocarcinoma are cured with chemotherapy; however, some (<5.0%) will die as a result of multi-drug resistance, underscoring the need for novel approaches in this group of patients. Although there are limited data due to its rarity, the treatment response with immunotherapy is high, ranging between 50-70%. Novel combinations of immune checkpoint inhibitors with targeted therapies (including VEGFR-2 inhibitors) are under evaluation. PD-L1 inhibitors are considered a potential important opportunity for chemo-resistant patients, and to replace or de-escalate chemotherapy to avoid or minimize chemotherapy toxicity. In this review, the Rare Tumor Working Group and the European Organization for Research and Treatment of Cancer evaluated the current landscape and further perspective in the management of patients diagnosed with gestational choriocarcinoma.

Incidence and characteristics of ovarian cancer following endometrial cancer in the emerging era of conservative management of endometrial cancer-Implications for counseling-A SEER analysis

OBJECTIVE

To assess the ovarian cancer (OC) risk following endometrial cancer (EC) in patients who underwent ovarian preservation as part of the EC staging.

STUDY DESIGN

With permission of the Surveillance, Epidemiology and End Results (SEER) program of the United States National Cancer Institute, clinicopathological information of women diagnosed with EC and following OC were analyzed. Incidence of OC and survival according to the surgical approach were studied. Primary analysis was conducted in women up to and including the age of 49 years.

RESULTS

A total of 116 patients up to the age of 49 years were diagnosed with EC and following OC. In this group of patients, no differences in incidence (IRR 0.9, CI 0.56-1.49, p = 0.66) or survival rates (p = 0.71) were found comparing ovarian preservation and bilateral salpingo-oophorectomy (BSO) performance. In an overall analysis of women diagnosed with EC and following OC at any age, incidence of OC did not differ between groups (IRR 1.07, CI 0.83-1.39, p = 0.59) yet when including patients older than 49 years old survival rates were shorter in ovarian preservation patients compared to patients with BSO performed as part of their EC treatment.

CONCLUSION

Ovarian preservation in EC patients under the age of 49 years may be considered safe, with no impact on OC incidence or survival, benefiting longer natural hormonal status.

A randomized-controlled trial assessing the effect of intraoperative acupuncture on anesthesia-related parameters during gynecological oncology surgery

CONTEXT AND OBJECTIVES

The present study examined the impact of intraoperative acupuncture on anesthesia-related parameters in patients undergoing gynecological oncology surgery.

METHODS

Participants underwent preoperative integrative oncology (IO) touch/relaxation treatments, followed by intraoperative acupuncture (Group A); preoperative IO treatments without acupuncture (Group B); or standard care only (Group C). Mean arterial pressure (MAP), heart rate (HR), MAP variability (mean of MAP standard deviation), bispectral index (BIS), and calculated blood pressure Average Real Variability (ARV) were measured intraoperatively.

RESULTS

A total of 91 patients participated: Group A, 41; Group B, 24; Group C, 26. Among patients undergoing open laparotomy, Group A showed lower and more stable MAP and HR compared to Group B, (MAP, p = 0.026; HR, p = 0.029) and Group C (MAP, p = 0.025). Mean BIS, from incision to suture closing, was lower in Group A (vs. controls, p = 0.024). In patients undergoing laparoscopic surgery, MAP was elevated within Group A (p = 0.026) throughout surgery, with MAP variability significantly higher in Group A (P = 0.023) and Group B (P = 0.013) 10 min post-incision (vs. pre-incision). All groups showed similar intraoperative and post-anesthesia use of analgesic medication.

CONCLUSION

Intraoperative acupuncture was shown to reduce and stabilize MAP and HR, and reduce BIS in gynecology oncology patients undergoing laparotomy, with no impact on perioperative analgesic medication use. In the laparoscopic setting, intraoperative acupuncture was associated with elevated MAP. Further research is needed to explore the hemodynamic and BIS-associated benefits and risks of intraoperative acupuncture, and the impact on the use of analgesic drugs in response to these changes.

Acupuncture during gynecological oncology surgery: A randomized controlled trial assessing the impact of integrative therapies on perioperative pain and anxiety

BACKGROUND

In this study, the impact of a multimodal integrative oncology pre- and intraoperative intervention on pain and anxiety among patients undergoing gynecological oncology surgery was explored.

METHODS

Study participants were randomized to three groups: Group A received preoperative touch/relaxation techniques, followed by intraoperative acupuncture; Group B received preoperative touch/relaxation only; and a control group (Group C) received standard care. Pain and anxiety were scored before and after surgery using the Measure Yourself Concerns and Wellbeing (MYCAW) and Quality of Recovery (QOR-15) questionnaires, using Part B of the QOR to assess pain, anxiety, and other quality-of-life parameters.

RESULTS

A total of 99 patients participated in the study: 45 in Group A, 25 in Group B, and 29 in Group C. The three groups had similar baseline demographic and surgery-related characteristics. Postoperative QOR-Part B scores were significantly higher in the treatment groups (A and B) when compared with controls (p = .005), including for severe pain (p = .011) and anxiety (p = .007). Between-group improvement for severe pain was observed in Group A compared with controls (p = .011). Within-group improvement for QOR depression subscales was observed in only the intervention groups (p <0.0001). Compared with Group B, Group A had better improvement of MYCAW-reported concerns (p = .025).

CONCLUSIONS

A preoperative touch/relaxation intervention may significantly reduce postoperative anxiety, possibly depression, in patients undergoing gynecological oncology surgery. The addition of intraoperative acupuncture significantly reduced severe pain when compared with controls. Further research is needed to confirm these findings and better understand the impact of intraoperative acupuncture on postoperative pain.

PLAIN LANGUAGE SUMMARY

Integrative oncology programs are increasingly becoming part of supportive/palliative care, with many working within the Society for Integrative Oncology. This study examined the impact of a multimodal integrative oncology program on pain and anxiety among 99 patients undergoing gynecological oncology surgery. Participants were randomized to three groups: preoperative touch/relaxation treatments, followed by intraoperative acupuncture; preoperative touch/relaxation without acupuncture; and a control group receiving standard care only. The preoperative touch/relaxation intervention significantly reduced perioperative anxiety, with the addition of intraoperative acupuncture significantly reducing severe pain as well, when compared with controls. Further research is needed to confirm these findings.

Endometrial carcinosarcoma

Endometrial carcinosarcoma is a rare and aggressive high-grade endometrial carcinoma with secondary sarcomatous trans-differentiation (conversion theory). The clinical presentation and diagnostic work-up roughly align with those of the more common endometrioid counterpart, although endometrial carcinosarcoma is more frequently diagnosed at an advanced stage. Endometrial carcinosarcoma is not a single entity but encompasses different histological subtypes, depending on the type of carcinomatous and sarcomatous elements. The majority of endometrial carcinosarcomas are characterized by p53 abnormalities. The proportion of POLE and microsatellite instablity-high (MSI-H) is directly related to the epithelial component, being approximately 25% and 3% in endometrioid and non-endometrioid components.The management of non-metastatic disease is based on a multimodal approach with optimal surgery followed by (concomitant or sequential) chemotherapy and radiotherapy, even for early stages. Palliative chemotherapy is recommended in the metastatic or recurrent setting, with carboplatin/paclitaxel doublet being the first-line regimen. Although the introduction of immunotherapy plus/minus a tyrosine kinase inhibitor shifted the paradigm of treatment of patients with recurrent endometrial cancer, patients with endometrial carcinosarcoma were excluded from most studies evaluating single-agent immunotherapy or the combination. However, the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) approved the use of pembrolizumab and lenvatinib in endometrial cancer (all histotypes) after progression on chemotherapy and single-agent immunotherapy in MSI-H cancers. In the era of precision medicine, emerging knowledge on molecular endometrial carcinosarcoma is opening new promising therapeutic options for more personalized treatment. The present review outlines state-of-the-art knowledge and future directions for patients with endometrial carcinosarcoma.

[GESTATIONAL TROPHOBLASTIC DISEASE: THE NEED FOR CENTRALIZATION OF TREATMENT CENTERS IN ISRAEL]

Gestational trophoblastic disease comprises a spectrum of pregnancy-related disorders, consists of premalignant disorders of complete and partial hydatidiform mole, and malignant disorders such as invasive mole, choriocarcinoma, and the rare placental-site trophoblastic tumor/epithelioid trophoblastic tumor. These malignant forms are termed Gestational Trophoblastic Neoplasia (GTN). Until the early 1960's, hysterectomy was the treatment of choice for women with malignant trophoblastic diseases. The five-year survival rate was 40% for local disease, and around 20% in women with metastases. Chemotherapy, treatment according to the various risk factors and the use of β-hCG values as a marker for monitoring the disease, resulted in a cure rate exceeding 98%, while preserving patient's fertility. Due to its` extremely low incidence with relatively complex treatment protocols, in the presence of high potential for side effects, in most countries there are tertiary centers that coordinate the treatment and follow-up of these diseases. In this review, we will summarize strategies for the primary management of gestational trophoblastic disease, the evaluation and management of malignant gestational trophoblastic neoplasia (GTN) and surveillance after treatment.

Breast Cancer Patients Are at Increased Risk of Developing Uterine Serous Cancer: Implications for Counseling - A SEER Analysis

INTRODUCTION

Several studies have investigated whether patients with prior breast cancer (BC) are at an increased risk for endometrial cancer (EC)/uterine serous cancer (USC). We aimed to study this relationship and analyze the effect of prior BC on the incidence and prognosis of USC patients.

METHODS

With permission of the Surveillance, Epidemiology, and End Results (SEER) program of the US National Cancer Institute, clinicopathological information of women diagnosed with BC and following USC were analyzed. The recorded data included age at diagnosis, stage of disease, cause of death, interval time between BC and USC diagnosis, and overall survival.

RESULTS

The SEER database included 10,021 patients with USC during the years 1975-2015. 698 (6.96%) of these patients had been previously diagnosed with BC. The incidence of USC in patients with BC history was 57 times higher than in women without BC history (p value <0.001). The incidence of USC did not differ between estrogen receptor (ER)-positive and ER-negative BC patients (p value 0.94). The mean survival of USC patients with previous BC history was 8 years (96 months, 95% CI: 85.7-106.2), shorter than in USC patients with no BC history, presenting a mean survival of 10.6 years (127 months, 95% CI: 124.0-130.8) (p value = 0.002).

CONCLUSION

Our results highlight the relationship between BC and USC, suggesting an increased risk for USC among BC patients. This clinical association should be introduced to BC patients, and physicians should be alert to any EC presenting symptom in BC survivors.

Attitudes of Israeli gynecologists towards risk reduction salpingo-oophorectomy at hysterectomy for benign conditions and the use of hormonal therapy

OBJECTIVES

To investigate the perspectives and attitudes of gynecologists towards risk reduction bilateral salpingo-oophorectomy (RRBSO) in average-risk women at the time of hysterectomy procedure for benign indications divided by age groups, and whether they recommend the use of hormonal therapy post oophorectomy.

METHODS

A questionnaire was distributed during staff meetings either by a printed questionnaire or by a link to a total number of 360 gynecologists include seniors and practitioners. Three hundred and one gynecologists participated in a national survey. Participants completed a structured questionnaire including three different scenarios. The subject group included both attending (senior) and second-year and above resident gynecologists, from divergent subspecialties. The demographic information of the survey responders included sex, age, years of experience, working domain, and subspecialty.

RESULTS

There was a 95% consensus rate among Israeli gynecologists, in favor of the ovarian conservation approach among 45-year-old women, elected for hysterectomy due to benign indications. Whereas in 50-year-old perimenopause women, without any evident family history of ovarian cancer, 39% of gynecologists advocated BSO at the time of hysterectomy, for benign indications. As for 46-year-old women, with a first-degree relative diagnosed with ovarian cancer at the age of 65 years old, 70.4% voted for prophylactic BSO. For the second part of the questionnaire regarding the utilization of hormone therapy (HT) after BSO, 66.1% of our responders proclaimed they would always encourage the use of HT in 45-year-old-women, while 52.8% recommended HT in 46-year-old-women with a family history of ovarian cancer and 39.5% for 50-year-old perimenopause women.

CONCLUSION

Our national survey confirms the wide variability in attitudes among gynecologists towards performing RRBSO at hysterectomy for a benign indication in women aged 45-50, with family history being a major factor in the decision.

Prognosis of Human Papillomavirus-Negative Compared to Human Papillomavirus-Positive Cervical Cancer

OBJECTIVES

The aims of the study were to evaluate the prevalence and prognosis of human papillomavirus (HPV)-negative cervical cancer (CC) and to compare these to data for HPV-positive CC.

MATERIALS AND METHODS

This retrospective cohort study compared between HPV-negative CC and HPV-positive CC patients. Primary end points were disease-free survival and overall survival. Secondary end points were demographic and clinical variables including histological diagnosis, stage, and treatment.

RESULTS

Of 233 women with CC, 18 (8%) tested HPV-negative. During a median follow-up of 45 months, 33 (14%) recurrences and 41 (18%) deaths were observed. Eleven of the 18 women (61%) who tested HPV-negative and 41 of the 215 (19%) who tested HPV-positive had only adenocarcinoma (p < .001). In a multivariate logistic regression analysis, advanced age (p = .003) and primary treatment with chemotherapy and/or radiotherapy (p < .001) remained statistically significant for recurrence or mortality (disease-free survival). The factors associated with lower survival were advanced age (p = .008), higher stage at diagnosis (p < .001), and HPV negativity (p = .062). Median overall survival for HPV-positive CC was not reached, compared with 24 months for HPV-negative CC. Kaplan-Meier curves showed lower rates of disease-free survival (p = .008) and overall survival (p = .011), for women with HPV-negative compared with HPV-positive CC.

CONCLUSIONS

The relatively poor prognosis of HPV-negative CC is important in light of its relatively high prevalence, which could increase proportionally to HPV-positive CC due to increased HPV screening and vaccination. Further studies are needed to confirm whether HPV status is truly an independent prognostic factor in CC.

Enhanced Recovery after Surgery is Feasible and Beneficial and Should Be the Standard in Major Gynecological Surgeries

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols are evidence-based protocols designed to standardize medical care, improve outcomes, and lower healthcare costs.

OBJECTIVES

To evaluate the implementation of the ERAS protocol and the effect on recovery during the hospitalization period after gynecological laparotomy surgeries.

METHODS

We compared demographic and clinical data of consecutive patients at a single institute who underwent open gynecological surgeries before (August 2017 to December 2018) and after (January 2019 to March 2020) the implementation of the ERAS protocol. Eighty women were included in each group.

RESULTS

The clinical and demographic characteristics were similar among the women operated before and after implementation of the ERAS protocol. Following implementation of the protocol, decreases were observed in post-surgical hospitalization (from 4.89 ± 2.56 to 4.09 ± 1.65 days, P = 0.01), in patients reporting nausea symptoms (from 18 (22.5%) to 7 (8.8%), P = 0.017), and in the use of postoperative opioids (from 77 (96.3%) to 47 (58.8%), P < 0.001). No significant changes were identified between the two periods regarding vomiting, 30-day re-hospitalization, and postoperative minor and major complications.

CONCLUSIONS

Implementation of the ERAS protocol is feasible and was found to result in less postoperative opioid use, a faster return to normal feeding, and a shorter postoperative hospital stay. Implementation of the protocol implementation was not associated with an increased rate of complications or with re-admissions.

The Association Between Clearance of Human Papillomavirus After Conization for Cervical Cancer and Absence of Cancer

OBJECTIVES

We assessed the relation between clearance of high-risk human papillomavirus (HR-HPV) after large loop excision of the transformation zone (LLETZ) and absence of residual disease, in women diagnosed with cervical cancer (CC) and adenocarcinoma in situ (AIS).

MATERIALS METHODS

Data were collected from 92 women diagnosed with CC and AIS who were positive to HR-HPV and had a repeat cervical HPV test 3-12 weeks after LLETZ (in which CC/AIS were diagnosed) and before final surgical treatment. We compared characteristics of women with negative and positive HR-HPV after LLETZ.

RESULTS

The HR-HPV results after the LLETZ operation were negative in 40 women and positive in 52 women. The HR-HPV-negative group included a significantly higher incidence of AIS: 14 (35%) vs 5 (9.6%, p < .006).In the negative HR-HPV post-LLETZ group, 36 (90%) had normal histology and only 2 (5%) had cancer in the final histological specimen. Among 34 women who underwent radical hysterectomy/trachelectomy after LLETZ, a normal final histology was observed in 75% and 9% of those who were HR-HPV negative and HR-HPV positive, respectively (p < .0005). The positive predictive value for absence of residual cancer, with clearance of HR-HPV after LLETZ, was 95%.

CONCLUSIONS

Clearance of HR-HPV from the cervix a short time after LLETZ has a high association with the absence of residual cancer in the final outcome, either in the pathology or the follow-up. Testing for HR-HPV a short time after LLETZ might serve as a parameter for risk assessment.

End-of-life Care Among Gynecological Oncology Patients in a Single Institute in Israel

BACKGROUND

Early referral to palliative care services in patients with advanced cancer is widely accepted. In addition, the use of futile intervention at the end of life is a pivotal aspect of assessing quality of care at that time.

OBJECTIVES

To evaluate the use of palliative care and aggressive treatments during the last month of life in women with gynecological malignancies.

METHODS

The study was designed in two steps. The first step included a retrospective analysis of a gynecologic oncology cohort that underwent end-of-life (EOL) care. In the second part, a questionnaire regarding EOL care was completed by family members. Since our palliative care service became more active after 2014, we compared data from the years 2013-2014 to the years 2015-2019.

RESULTS

We identified 89 patients who died from gynecological malignancy during study period; 21% received chemotherapy and 40% underwent invasive procedures during their last month of life. A palliative care consultation was documented for 49% of patients more than one week before their death. No statistical difference was achieved between the two time periods regarding the use of chemotherapy or invasive procedures in the last month of life. Nonetheless, after the incorporation of palliative medicine more women had palliative care consultations and had EOL discussions. Most of the patients' relatives were satisfied with EOL care.

CONCLUSIONS

Many aggressive interventions were given during the last month of life. EOL discussions were documented in the medical charts of most patients and the rates increased with time.

Outcomes of diagnosed COVID-19 cancer patients: concerning results of a systematic review

Since the outbreak of coronavirus disease 2019 (COVID-19), malignancy was shown to be prevalent in COVID-19 patients. This systematic review's searches were conducted in MEDLINE(R), Embase, Web of Science, and Scopos. Considered for inclusion were all reports on outcomes of cancer patients diagnosed with COVID-19. A total of 1099 references were identified through database searching and manual search. Finally, 17 references comprising 88 cancer patients, diagnosed with COVID-19, were included. Prevalence of cancer patients with COVID-19 was shown to range from 0.9% to 3%. The evidence suggested a severe clinical course of 50.6% in COVID-19 diagnosed cancer patients and a mortality rate of 34.5%. Subgroup analysis according to recent anti-cancer treatment showed a similar pattern, with the most concerning results in patients receiving recent immunotherapy/immunosuppressive treatment. COVID-19 morbidity and mortality among cancer patients should be reduced by consideration of testing asymptomatic COVID-19 cancer patients, reduction of hospital visits, and consideration of anti-cancer treatment.

Consequences of the COVID-19 pandemic on the postpartum course: Lessons learnt from a large-scale comparative study in a teaching hospital

Objective

To evaluate the consequences of COVID‐19 pandemic restrictions on the postpartum course.

Methods

A retrospective cross‐sectional study compared women who gave birth between March and April 2020 (first wave), between July to September 2020 (second wave), and a matched historical cohort throughout 2017–2019 (groups A, B, and C, respectively). Primary outcomes were postpartum length of stay (LOS), presentations to the emergency department (ED), and readmissions 30 days or longer after discharge. Following Bonferroni correction, p < 0.016 was considered statistically significant.

Results

In total, 3377 women were included: 640, 914, and 1823 in groups A, B, and C, respectively. LOS after birth (both vaginal and cesarean) was shorter in groups A and B compared to the control group (2.28 ± 1.01 and 2.25 ± 0.93 vs 2.55 ± 1.10 days, p < 0.001). Rates of ED presentations 30 days after discharge were higher in groups C and B compared to group A (6.63% and 6.45% vs 3.12%, p = 0.006). Rates of readmissions 30 days after discharge were 0.78%, 1.42%, and 1.09% (groups A, B, and C, respectively), demonstrating no statistical difference (p = 0.408).

Conclusion

During the COVID‐19 pandemic, there was a reduction or no change in rates of ED presentations and readmissions, despite the shortened LOS after delivery. A shift in policy regarding the postpartum LOS could be considered.

Length of stay after delivery was shortened during the COVID‐19 pandemic without a surge in postpartum presentations to the emergency department or rates of readmission.

Should the risk for uterine cancer influence decision making for prophylactic hysterectomy in BRCA1/2 mutated patients- a systematic review and meta-analysis

OBJECTIVE

To study the possible association between uterine cancer and the BRCA1/2 associated cancer syndrome and discuss the implications of such an association on the clinical managment of patients with BRCA1/2 mutations.

METHODS

A systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement. Study protocol was prospectively registered at PROSPERO International prospective register of systematic reviews (registration number CRD42020193496). Considered for inclusion were studies providing the diagnosis rate of uterine cancer in patients with BRCA1/2 mutations by comparing observed and expected rate according to a known disease incidence. The results were measured by standardized incidence ratio (SIR). The primary outcome was defined as any uterine cancer diagnosis and subgroup analyses were conducted for uterine serous papillary cancer (USPC) specifically and for BRCA1 and BRCA2 mutations separately.

RESULTS

4591 records were identified through database search; eight studies were finally included, comprising 13,098 patients with BRCA1/2 mutations. BRCA1/2 mutated patients were found to have a significantly higher risk for uterine cancer compared to the general population (SIR = 2.22, 95% CI 1.76-2.8, p < 0.001). A higher incidence of USPC was also found in patients with BRCA1/2 mutations (SIR = 17.97, 95% CI 9.89-32.66, p < 0.001), as well as in a separate analysis for BRCA1 (SIR = 2.81, 95% CI 2.09-3.79, p < 0.001) and BRCA2 (SIR = 1.75, 95% CI 1.09-2.80, p < 0.001) mutations.

CONCLUSION

Patients who carry a BRCA1/2 mutation are at a significantly higher risk of developing uterine cancer, specifically USPC, supporting that USPC may be a component of the BRCA1/2 syndrome. The decision to perform concurrent hysterectomy at the time of the risk reduction bilateral salpingo -oophorectomy surgery should be considered individually.

Changes in the obstetrical emergency department profile during the COVID-19 pandemic

BACKGROUND

The COVID-19 outbreak caused persons to be reluctant to seek medical care due to fear of contracting the infection.

OBJECTIVES

To evaluate the effect of the COVID-19 pandemic on admission rates to the delivery room and the feto-maternal unit, and to assess the effect on the nature of presenting obstetrical complaints to the emergency department.

STUDY DESIGN

A retrospective cohort study in one medical center. The population was women > 20 weeks pregnant who presented to the obstetrical emergency department with self-complaints during 29 days at the peak of the pandemic outbreak, and a matched group during the exact period in the previous year. We compared between the groups: clinical, obstetrical, and demographic data, including age, area of residence, gravidity, parity, previous cesarean deliveries, high-risk pregnancy follow-up, the last 30 days admissions to the obstetrical emergency department, gestational age, chief complaints, cervical dilatation, cervical effacement, admissions to the delivery room or feto-maternal unit, time from admissions to the delivery room to birth, if applicable, and acute obstetrical complications diagnosed at the emergency department.

RESULTS

During the pandemic outbreak, 398 women met study inclusion criteria, compared to 544 women in the matched period of the previous year. During the COVID-19 period, women visited the obstetrical emergency department at a more advanced mean gestational age (37.6 ± 3.7 vs. 36.7 ± 4.6, p = .001). Higher proportions of women in the COVID-19 cohort presented in active labor, defined by cervical dilation of at least 5 cm on admission to the labor ward [37 (9.3%) vs 28 (5.1%), p = .013)] and with premature rupture of membranes [82 (20.6%) vs 60 (11.0%), p < .001)], and consequently with more admissions to the delivery room [198 (49.7%) vs 189 (34.7%), p < .001)]. We also recorded a significant increase in urgent obstetrical events in the emergency department during the recorded COVID-19 pandemic [23 (5.8%) vs 12 (2.2%)), p = .004]. However, the rates of neonatal and maternal morbidity did not change. During the outbreak the proportion of visits during the night was higher than during the matched period of the previous year: [138 (34.7%) vs 145 (26.6%)), p = .008]. In a multivariate logistic regression, the higher rates of admission to the delivery room during active labor and of urgent events during the pandemic outbreak compared to the matched period in the previous year remained statistically significant.

CONCLUSIONS

The pandemic outbreak of COVID-19 caused a behavioral change among women who presented to the obstetrical emergency department. This was characterized by delayed arrival to the obstetrical emergency department and the delivery room, which led to a significant increase in urgent and acute interventions. The change in behavior did not affect the rates of maternal and neonatal morbidity.

Five-year survival decreases over time in patients with BRCA-mutated ovarian cancer: a systemic review and meta-analysis

Introduction

Short-term survival rates of patients with BRCA-mutated ovarian cancer have been previously shown to be longer than those of non-carriers. We aimed to study the long-term survival rates of these patients and investigate whether the 5-year advantage decreases over time.

Methods

A systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyzes (PRISMA) statement. The study protocol can be assessed at PROSPERO International prospective register of systematic reviews (http://www.crd.york.ac.uk/PROSPERO, registration number CRD42019137455). We considered for inclusion studies providing Kaplan–Meier survival curves up to and including 10 years, comparing patients with ovarian cancer with and without BRCA mutations. Our main outcome was the conditional probability of surviving an additional 5 years.

Results

A total of 13 references comprising 4565 patients was analyzed, of which 1131 BRCA1/2-mutated carriers and 3434 non-carriers were included. The expected higher 5-year survival rate in BRCA-mutated patients was observed (risk difference (RD)=14.9%, p=0.0002, risk ratio (RR)=1.36, p=0.001). Ten-year survival rates were comparatively less improved in BRCA-mutated patients (RD=8.6%, p=0.042, RR=1.25, p=0.12). After already surviving 5 years, no advantage in probability of further surviving 5 additional years was observed for the BRCA-mutated group (RD=2.9%, p=0.71, RR=0.97, p=0.78).

Conclusion

Our results provide insight into long-term survival rates and prognosis in patients with BRCA-mutated ovarian cancer which suggest that, despite the improved 5-year prognosis, the conditional probability of surviving an additional 5 years does not show the same advantage. The relatively low long-term advantage highlights the significance of epithelial ovarian cancer recurrence prevention. In the era of poly adenosine ribose inhibitors, future studies should explore the adequate follow-up and the benefit of a longer maintenance treatment phase, aiming to prolong the long-term survival of BRCA-mutated patients.

0128 Mild Upper Airway Obstruction Leads to Increased Energy Intake and Growth Retardation that Persists After the Obstruction Removal

Introduction

Whereas pediatric obstructive sleep apnea may cause insufficient body weight gain and growth retardation, in some studies, metabolic syndrome and obesity were observed. Interestingly, treatment by adenotonsillectomy can lead to accelerated weight gain by an unclear mechanism. Here, we explored the effects of moderate upper airway obstruction (AO) and mild AO (mAO) and its removal (OR) on ventilation, resting energy expenditure (REE), food intake and growth during the diurnal cycle, from weaning to adulthood.

Methods

The trachea of 22-day-old rats was surgically narrowed to generate AO, mAO, and OR was performed after two weeks on mAO animals. Minute ventilation was recorded by whole body plethysmography and diurnal food intake, and REE was explored with metabolic cages 12 weeks post surgery.

Results

Following tracheal narrowing, inspiratory swings in esophageal pressure increased by 177% (p&lt;0.01) and 36% (p&lt;0.01) in AO and mAO rats, respectively, and was similar to the controls in the OR group. REE (Kcal/h/kg) was 3.7±0.1, 5.7±0.12 (p&lt;0.01), 4.1±0.08 (p&lt;0.01), and 3.6±0.15 in the control, AO, mAO, and OR groups, respectively. Increased EE in the AO and mAO groups was associated with up-regulation of ventilation by 133% and 56%, respectively (p&lt;0.01). In all groups, energy intake (EE) was higher during a 12 h active period compared to a sleep period (p&lt;0.01). EE during the lights on of AO and mAO animals increased by 136 % and 126%, respectively, and was similar to the control in the OR group. Active period EE increased by 19% in both obstructed groups (p&lt;0.01). Active period EE was 16.7 % higher in the OR group despite the normalization of ventilation and tracheal diameter to the control value. Increased REE was associated with hindrance of bone elongation (p&lt;0.01), and OR partially improved growth.

Conclusion

The need to maintain respiratory homeostasis during upper airway obstruction was associated with a persistent increase in energy intake. Surgical intervention may not be sufficient to correct the energy intake elevation, and endocrine regulation of feeding and growth may have greater impacts post intervention.

Support

This study was supported by the Israel Science Foundation grant no. 164/2018

[PARP INHIBITORS FOR ADJUVANT TREATMENT FOR OVARIAN CANCER]

Treatment for ovarian cancer has been challenging for many years. It is composed of debulking surgery and chemotherapy. During the first line of treatment most patients are sensitive to primary platinum-based chemotherapy, however, unfortunately, most of them will suffer from recurrence in 36 months. About 20-25% of ovarian cancer patients exhibit a germ line mutation in the pathway of double strand DNA repair including BRCA. Poly ADP ribose polymerase inhibitors (PARP Inhibitors) may inhibit enzymes responsible for single strand DNA repair, thus leaving the BRCA mutated cell without a repair mechanism for DNA damage leading to synthetic lethality. Recently, phase 3 studies have shown that ovarian cancer patients with recurrent, platinum sensitive disease who were treated with PARP inhibitors have shown statistically significant improvement in progression free survival. A recent pivotal trial has shown the addition of PARP inhibitor, as a maintenance treatment after first line chemotherapy to ovarian cancer patients with BRCA mutation, had significantly increased the progression-free survival. The side effect profile of PARP inhibitors was tolerable and manageable, although they should be well familiar to care givers. Following these studies, the FDA and the European authorities granted an accelerated approval for the use of PARP inhibitors as maintenance treatment after first line treatment, for BRCA carriers, and at the recurrence for platinum sensitive patients. Subsequently, it was added to the benchmark medications for recurrent platinum sensitive BRCA carriers (germ line or somatic) by the Ministry of Health in Israel. The future seams to provide new combination treatments of PARP inhibitors with immunological agents and vascular endothelial growth factors inhibitors aiming to improve the poor prognosis of ovarian cancer patients.

The added benefit of transvaginal sonography in the clinical staging of cervical carcinoma

INTRODUCTION

Patients diagnosed with cervical cancer face several treatment options, depending on the physical examination and the imaging modality results. Transvaginal sonography (TVS) was proposed as an imaging option to determine local spread of cervical tumors, along with magnetic resonance imaging, also by recently released International Federation of Gynecology and Obstetrics recommendations. We examined whether combined data from physical examination, high-detail TVS, and positron emission tomography with ¹⁸ F-labeled fluoro-2-deoxyglucose and computed tomography (¹⁸ F-FDG PET/CT) may contribute to triage efficiency of cervical cancer patients.

MATERIAL AND METHODS

This is a retrospective study of consecutive women diagnosed with cervical cancer at the Carmel Health Center, Haifa, Israel, during 2010-2015. Inclusion criteria were histology of cervical cancer and the availability of three modalities-a thorough physical examination, a high-detail TVS, and positron emission tomography (PET) with ¹⁸ F-FDG and computed tomography (¹⁸ F-FDG PET/CT). End points were the possibility to predict local invasion to the parametrium and distant lymph node metastasis at the time of triage to surgery or chemoradiation.

RESULTS

Seventy-three patients with cervical cancer were evaluated. TVS correctly predicted no involvement of the parametrium for the 25 who had a postoperative pathological report. TVS measurement of tumor dimension was also matched by the pathological report in these cases. Only three patients were referred for adjuvant therapy according to postoperative pathology criteria. Among 43 women treated with a combination of chemotherapy and radiotherapy due to advanced disease, and with complete data, at least two modalities were congruent with chemoradiation for 33 (77%). Three patients (7%) were referred to chemoradiation due to TVS result alone.

CONCLUSIONS

The combination of high-detail TVS, directed to predict tumor dimensions and local spread, performed by a trained operator, combined with ¹⁸ F-FDG PET/CT and physical examination, can assist in selecting optimal treatment for cervical cancer patients, thus avoiding unnecessary operations.

An Israeli Gynecologic Oncology Group study of statin use and endometrial cancer prognosis

OBJECTIVE

To assess whether statin use by endometrial cancer patients was associated with a survival advantage.

METHODS

A retrospective chart review study, by the Israeli Gynecologic Oncology Group, of consecutive endometrial cancer patients who underwent surgery in one of 11 medical centers between 2002 and 2014. Clinical and pathological reports, and measures of survival were compared between statin users and nonusers. Kaplan-Meier and Cox proportional hazard models were used to assess the effect of using statins on survival measures.

RESULTS

Over a mean follow-up period of 6.2 years (range, 1-12 years) for 2017 endometrial cancer patients with complete data, 663 (32.8%) used statins prior to diagnosis and 1354 (67.1%) did not. No statistically significant differences between the groups were observed for most demographic and clinical characteristics. There was no difference between statin users and nonusers in 5-year recurrence-free survival (82% vs 83%; P=0.508), disease-specific survival (86% vs 84%; P=0.549), or overall survival (77% vs 75%; P=0.901).

CONCLUSIONS

In this large cohort of patients with endometrial cancer, no significant associations were found between use of statins and endometrial cancer survival.

Cervical Cancer with Intermediate Risk Factors: Is there a Role for Adjuvant Radiotherapy? A Systematic Review and a Meta-Analysis

BACKGROUND

The yield of adjuvant radiotherapy in cervical cancer patients with intermediate risk factors is controversial. The objective of our meta-analysis was to shed light on this important issue.

MATERIAL AND METHODS

Search was conducted in several databases. By independent screening of titles and abstracts, 2 investigators selected original researches examining the effect of adjuvant radiation treatment on overall survival and progression-free survival in cervical cancer patients with intermediate risk factors.

RESULTS

Of the 5 articles included, a total of 591 patients with intermediate risk factors were encompassed. Statistical significance was noted in favor of radiation therapy in a subgroup of patients with 2 or more intermediate factors in terms of recurrence (OR 0.46 [95% CI 0.28-0.74, p = 0.001]) and overall survival (OR 1.86 [95% CI 1.03-3.36, p = 0.04]). After adding patients with one risk factor, radiation exerted a non-significant effect on recurrence rate, overall survival, disease-free survival, and 5-year cancer-specific survival, while increasing the rate of gastrointestinal side effects (2.4 vs. 0%, p = 0.0156).

CONCLUSIONS

Adjuvant radiation therapy decreases the risk for recurrence and increases the overall survival in patients with 2 intermediate risk factors. These benefits were not shown after adding patients with one risk factor.

Is there a survival advantage in diagnosing endometrial cancer in asymptomatic postmenopausal patients? An Israeli Gynecology Oncology Group study

BACKGROUND

Incidental ultrasonographic findings in asymptomatic postmenopausal women, such as thickened endometrium or polyps, often lead to invasive procedures and to the occasional diagnosis of endometrial cancer. Data supporting a survival advantage of endometrial cancer diagnosed prior to the onset of postmenopausal bleeding are lacking.

OBJECTIVE

To compare the survival of asymptomatic and bleeding postmenopausal patients diagnosed with endometrial cancer.

STUDY DESIGN

This was an Israeli Gynecology Oncology Group retrospective multicenter study of 1607 postmenopausal patients with endometrial cancer: 233 asymptomatic patients and 1374 presenting with postmenopausal bleeding. Clinical, pathological, and survival measures were compared.

RESULTS

There was no significant difference between the asymptomatic and the postmenopausal bleeding groups in the proportion of patients in stage II-IV (23.5% vs 23.8%; P = .9) or in high-grade histology (41.0% vs 38.4%; P = .12). Among patients with stage-I tumors, asymptomatic patients had a greater proportion than postmenopausal bleeding patients of stage IA (82.1% vs 66.2%; P < .01) and a smaller proportion received adjuvant postoperative radiotherapy (30.5% vs 40.6%; P = .02). There was no difference between asymptomatic and postmenopausal bleeding patients in the 5-year recurrence-free survival (79.1% vs 79.4%; P = .85), disease-specific survival (83.2% vs 82.2%; P = .57), or overall survival (79.7% vs 76.8%; P = .37).

CONCLUSION

Endometrial cancer diagnosed in asymptomatic postmenopausal women is not associated with higher survival rates. Operative hysteroscopy/curettage procedures in asymptomatic patients with ultrasonographically diagnosed endometrial polyps or thick endometrium are rarely indicated. It is reasonable to reserve these procedures for patients whose ultrasonographic findings demonstrate significant change over time.

Constant rate infusion vs. intermittent bolus administration of IV furosemide in 100 pets with acute left-sided congestive heart failure: A retrospective study

The aim of this study was to determine whether the addition of constant rate infusion (CRI) to intermittent intravenous bolus (IVB) administration of furosemide resulted in an improvement in medical outcomes in dogs and cats with acute left-sided congestive heart failure (L-CHF). A total of 76 client-owned dogs and 24 client-owned cats admitted with acute L-CHF were retrospectively divided between an IVB group (43 dogs and 16 cats) and a CRI group (33 dogs and 8 cats). The median furosemide dose used in dogs in the CRI group (median 0.99mg/kg/h; range 0.025-3.73mg/kg/h) was lower than the dose used in dogs in the IVB group (median 1.19mg/kg/h; range 0.027-7.14mg/kg/h; P=0.008). Respiratory rates were lower in the IVB group (P=0.005) and the CRI group (P=0.039) compared to pre-treatment values. The overall short-term mortality was 15%. A trend of longer hospitalisation in the IVB group relative to the CRI group (P=0.07) was shown. Creatinine and total plasma protein concentrations increased more in the CRI group than in the IVB group, suggestive of a higher risk of dehydration and azotaemia. There may be safety profile differences between CRI and IVB, warranting a prospective study using a larger sample size.

Age-adjusted treatment of cervical intraepithelial 1 lesions by superficial or regular loop excision of transformation zone

BACKGROUND

The loop electrosurgical excision procedure (LEEP) is one of the treatments for cervical intraepithelial neoplasia 1 (CIN1). One of the risks of LEEP is preterm birth. We evaluated final pathological diagnoses following LEEP as treatment for CIN1 lesions, for procedures in which cone height was determined by patients' age.

METHODS

A retrospective study of 329 women diagnosed with CIN1 on a cervical biopsy and treated by LEEP. In patients under age 35 years, a thin LEEP COIN was performed, and in women over 35 years, a regular LEEP was performed.

RESULTS

The final pathological diagnosis was CIN2 and CIN3 in 14.6% of the women. The average excision height was 0.64 cm in women aged under 35 years, 0.82 cm in women aged 36-45 years, and 0.96 cm in women older than 46 (P<0.0001). Comparing excision height less than 0.8 cm to excision height above 0.9 cm, complications of the procedure, positive margins rates and recurrence rates were similar.

CONCLUSIONS

Among women of childbearing age, the performance of a LEEP procedure with smaller cone height appeared equivocal in achieving correct pathological diagnoses and low recurrence. To avoid increasing the risk of premature delivery, the excisional depth should be adjusted to age and fertility status.

Impact of BRCA mutations on outcomes among patients with serous endometrial cancer

OBJECTIVE

To compare the outcome of patients with uterine papillary serous cancer (UPSC) carrying a BRCA mutation with that of patients with UPSC who are BRCA wild-type.

METHODS

The present retrospective, multicenter cohort study included women with UPSC who were diagnosed between January 1, 1993, and December 31, 2014, and were tested for the BRCA mutation at three Israeli medical centers. Data were collected from the medical records, and patient and tumor characteristics and disease outcomes were compared between BRCA mutation carriers and noncarriers. The primary outcome was overall survival.

RESULTS

In total, 14 BRCA mutation carriers and 50 noncarriers were included. Both groups had similar treatment modalities (P=0.530). A non-significant trend toward BRCA mutation carriers being diagnosed more frequently at an advanced stage compared with noncarriers was observed (P=0.090). Median overall survival (25 vs 37 months; P=0.442), progression-free survival (37 vs 29 months; P=0.536), and disease-specific survival (60 vs 39 months; P=0.316) were similar between the carrier and noncarrier groups.

CONCLUSIONS

Although not significant, BRCA mutation carriers tended to have more advanced disease at diagnosis. However, the survival was similar irrespective of the BRCA status in this small group. Further research is needed to confirm these findings in a larger cohort.

The analgesic efficacy of forced coughing during cervical punch biopsy: A prospective randomised controlled study

INTRODUCTION

Cervical punch biopsies are a common ambulatory procedure, performed routinely by gynaecologists. The aim of the present study was to assess the efficacy of forced coughing as a pain-reducing technique during cervical punch biopsy compared to a control group.

MATERIALS AND METHODS

The study was a prospective randomised-control trial. The study group comprised 90 women who underwent cervical punch biopsies during investigation of abnormal Pap test results. The women were randomly assigned to 'cough' and control groups. Pain was measured on a 10 cm visual analogue scale (VAS) during different stages of the procedure.

RESULTS

VAS pain score during biopsies was significantly lower in the 'cough' group. The median pain level in the 'cough' group was 1.5, compared to 4.0 in the control group. Eighty percent of the women in the 'cough' group reported a pain level of 2.0 or less compared to 40% of the women in the 'control' group (P = 0.0002). In the second biopsy, 69% of the women reported VAS ≤ 2.0 in the cough group compared to 28% of the patients in the control group. Forced coughing was shown both to reduce anxiety regarding the prospect of future cervical procedures and to decrease patients' desires for future pain management. This was true for 32% of the women in the 'control' group compared to 12% of the women in the 'cough' group (P = 0.05).

CONCLUSION

Forced coughing provides significant pain relief during cervical punch biopsy and reduces the patients' fears and desires for pain medications in future procedures.

Prevalence and Genotype Distribution of HPV Types in Women at Risk for Cervical Neoplasia in Israel

BACKGROUND

Invasive cervical cancer is caused by human papillomavirus (HPV).

OBJECTIVES

To describe the prevalence and genotype distribution of HPV types in women at risk for cervical neoplasia.

METHODS

Our study summarized HPV types detected in 6654 samples that were sent to the serology laboratory from cervical clinics in northern Israel between 2006-2014. The HPV test was performed during investigation of atypical squamous cells of undetermined significance (ASCUS) results on Pap tests or due to complaints suggestive of cervical neoplasia. HPV types were classified as high risk (HPV-HR) and low risk (HPV-LR).

RESULTS

Of the samples, 46.4% (3085/6654) were HPV-HR positive. Of women with cervical intraepithelial neoplasia 2-3 (CIN 2-3) or cancer, 292/318 (91.8%) and 137/145 (94.5%), respectively, were HPV-HR positive. HPV 16 and HPV 18 were detected in 11.8% of the total samples and in 48.2% and 64.9% of the women with CIN 2-3 and with cancer, respectively. HPV was negative in 8/145 (5.5%) and 26/318 (8.2%) of women with cervical cancer and CIN 2-3, respectively.

CONCLUSIONS

This study shows the prevalence of HPV types in women at risk for cervical neoplasia. The sensitivity of all HPV types for CIN 2-3 and cervical cancer was 91.8% and 94.5%, respectively; and of HPV-HR types, 89% and 92.4%, respectively. Triage of HPV-HR types should be considered in women with ASCUS because HPV-HR types were discovered in only 36.7%. The distribution of HPV types in our population is similar to that reported for other developed countries.

[LOW GRADE OVARIAN CANCER]

According to the new and reproducible grading system of the MD Anderson Cancer Center (MDACC), low grade serous cancer (LGSC) differs greatly from the commonly known high grade serous cancer (HGSC). Pathology speaking, LGSC has less mitotic index; the grade of nuclear atypia is low to intermediate. Genetically speaking, these tumors tend to show mutation in the mitogen-activated protein kinase (MAPK) pathway, mainly in the KRAS and BRAF genes, resulting in uncontrolled proliferation; however, it seems that the presence of this mutation might be related to a better prognosis compared to their absence. The presenting symptoms and spread is similar to HGSC, such as the elevated Ca-125 and the advanced stage at the presentation. The rate of proliferation, on one hand affects the prognosis and therefore, although it tends to present in advanced stages such as HGSC, the prognosis is better. On the other hand, low proliferation might be the reason for the relative decrease in the sensitivity to the common chemotherapy given in HGSC. Treatment strategy, as well. is similar to HGSC consisting of debulking surgery followed by or after chemotherapy. Molecular and pathology studies confirm borderline tumor might be a precursor of some of LGSC, since it shares similar mutation pathways seen in LGSC. Those pathways are targets for newer chemotherapy agents, currently under phase II and III promising trials.

High Incidence of Carcinosarcoma among Patients Previously Treated with Tamoxifen

BACKGROUND

Tamoxifen acts as an estrogen antagonist within the breast tissue. In the uterus, tamoxifen is an agonist for some estrogen receptors and therefore can cause hyperplasia or neoplasia in the endometrium.

OBJECTIVES

To compare characteristics of patients with uterine sarcoma who were and were not previously treated with tamoxifen.

METHODS

The medical records of all women with uterine sarcoma who had been treated at the Carmel Medical Center in Haifa, Israel, during 2000-2013 were retrospectively reviewed. Disease characteristics, histological type of sarcoma, patient demographics, treatments and final outcomes were compared between patients who had and those who had not been exposed to tamoxifen.

RESULTS

Of the 66 patients identified, 14 (21%) had been exposed to tamoxifen, one of them for 3 years and 13 for at least 5 years. Mean ages were 69 ± 8 and 66 ± 12 years for those exposed and those not exposed to the drug, respectively. Rates of uterine carcinosarcoma were 86% (12/14) and 44% (23/52), respectively (P < 0.006). Patients with carcinosarcoma were older than other sarcoma patients (73 ± 7 vs. 59 ± 11 P < 0.005).There were no statistically significant differences between the two groups in rates of diabetes mellitus, hypertension, dyslipidemia or heart disease. The mean time from diagnosis to death was 7.37 ± 0.42 years. The overall survival rates of carcinosarcoma patients were not statistically different from that of other sarcoma patients. Tamoxifen exposure was not associated with overall survival among all sarcoma patients, nor among the subgroup of carcinosarcoma patients.

CONCLUSIONS

Tamoxifen treatment was associated with elevated incidence of carcinosarcoma among women with uterine sarcoma, but was not found to be associated with prognosis or with co-morbidities.

A phase 1/2a, dose-escalation, safety, pharmacokinetic, and preliminary efficacy study of intraperitoneal administration of BC-819 (H19-DTA) in subjects with recurrent ovarian/peritoneal cancer

BACKGROUND

H19 is a paternally imprinted, oncofetal gene expressed in various embryonic tissues and in 85% of the ovarian tumors. H19-DTA (BC-819) is a DNA plasmid that drives the expression of the diphtheria toxin gene under the regulation of the H19 promoter sequence and therefore is a potential treatment for various tumors that overexpress the H19 gene, among them-ovarian cancer.

OBJECTIVE

To assess the safety and efficacy of intra-peritoneal (IP) instillations of H19-DTA (BC-819) plasmid in treating ovarian/peritoneal cancer patients with advanced recurrent disease.

METHODS

A phase 1-2A multi-centric trial included 14 eligible patients who were either platinum-refractory or platinum-resistant with positive H19 expression. Patients were treated IP with escalating weekly doses of BC-819 for a maximum of 6-9 weeks. Dose-limiting toxicities (DLT) were assessed after the first course of treatment for each patient and each subsequent cohort was enrolled once each subject had completed the first course of treatment and its 4-week follow-up period. The occurrence of adverse events (AEs) and response to treatment were assessed after the induction course and then periodically.

RESULTS

During the study, no DLTs were observed. Only 5 grade 1 and 2 AEs, which occurred in 4 patients were considered as possibly related to BC-819. The best tumor response seen was stable disease. Median survivals of 3.2, 5.3 and 6.5 months were observed for the 60, 120 and 240 mg cohorts, respectively.

CONCLUSIONS

BC-819 can be considered safe and well tolerated in intraperitoneal doses up to 240 mg. Hybridization of intraperitoneal chemotherapy with the biological treatment of BC-819 should be further evaluated in phase 2 and 3 studies.

Vaginal cuff closure technique and the risk for infected pelvic hematoma after vaginal hysterectomy

OBJECTIVES

Infected pelvic hematoma is a relatively common complication of vaginal hysterectomy, manifesting with postoperative pain and fever which often necessitate surgical drainage. We aimed to assess the effect of the surgical technique for vaginal cuff closure on the incidence of this complication.

STUDY DESIGN

Until March 31, 2010, our surgical protocol for vaginal hysterectomy included complete vaginal cuff closure. After this date, all surgeries were performed using another technique, by which a patent tract was left at the vaginal cuff for drainage of blood, secretions and debris. We reviewed medical records of all women who underwent vaginal hysterectomy for pelvic organ prolapse in our institution between January 2006 and November 2015, including demographic, clinical and surgical data. We compared the incidence of postoperative infected pelvic hematomas before and after March 31, 2010.

RESULTS

We identified 325 women who underwent vaginal hysterectomy during the first time period (group I) and 243 women who underwent this procedure during the second time period (group II). While demographic and clinical data were not significantly different between the two groups, the incidence of infected pelvic hematomas necessitating hospitalization was significantly lower in group II (3.8% vs. 13.5%, p<0.0001).

CONCLUSIONS

A significant reduction in the incidence of infected pelvic hematoma following vaginal hysterectomy was noted using a surgical technique that allows for drainage of blood and debris through the vaginal cuff.

Appendectomy in Pregnancy: Appraisal of the Minimally Invasive Approach

BACKGROUND

The optimal surgical approach to acute appendicitis in pregnancy remains controversial. Our aim was to compare perioperative and obstetric outcomes associated with laparoscopic and open appendectomy in a large contemporary cohort of pregnant women.

METHODS

Retrospective review of all women who underwent appendectomy during pregnancy in a single hospital during 2000-2014.

RESULTS

Ninety-two patients met the study criteria. Fifty (54%) underwent laparoscopic appendectomy and 42 (46%) open appendectomy. The laparoscopy group had a lower median gestational age at surgery (16 weeks versus 24 weeks, P < .001), a shorter median hospital stay (5 days versus 3 days, P < .001), and a lower rate of postoperative complications (8% versus 24%, P = .04). There were no significant between-group differences in the rates of gestational age at delivery, Apgar scores, preterm delivery, and fetal loss.

CONCLUSIONS

Laparoscopic appendectomy during pregnancy is safe and associated with better surgical outcomes than open appendectomy, with no difference in obstetric outcomes.

The prevalence of HPV types in women with CIN 2-3 or cervical cancer in Haifa district, Israel

BACKGROUND

Human papilloma virus (HPV) is classified as a biologic carcinogen causing cervical cancer. Our aim was to identify all the HPV types responsible for cervical cancer and pre-cervical cancer in Israel.

METHODS

This study included 226 women, diagnosed with cervical intraepithelial neoplasia (CIN) 2-3 and 115 women diagnosed with cervical cancer, and tested for all HPV typing during the period of January 2006 to May 2013.

RESULTS

HPV was detected in 92.9% of women with CIN 2-3 and high-risk HPV (HR-HPV) was detected in 85.8% of them. In women with cervical cancer, HPV was positive in 96.5%, HR-HPV detected in 93%. In the CIN 2-3 group the most common HPV types were 16 (42%), 31 (8.8%) and 18 (4.9%) and in the cancer group HPV 16 (57.4%), 45 (9.6%), and 18 (7.8%). Multiple HPV types were seen in 12.8% of CIN 2-3 group but only in 0.9% of cancer group. The chief complaint led to cancer diagnosis was post menopause bleeding (27%), while abnormal Papanicolaou (Pap) test lead to CIN 2-3 diagnosis in 75.2% of the women. Only 22.6% of women diagnosed with cancer were diagnosed due to abnormal Pap test and 76.9% of them were diagnosed at stage I, as compared to women diagnosed with cancer because of bleeding or abnormal mass, of them 57.1 % were diagnosed at stage I (P<0.07).

CONCLUSIONS

HR-HPV types were found in 93% of cancer group and 85.8% of CIN 2-3 group, and low-risk HPV (LR-HPV) was detected in 3.5% and 7.1% of women with cervical cancer and CIN 2-3 respectively. The most common HPV types in cervical cancer women were 16, 45 and 18. Women diagnosed with cancer because abnormal Pap test were in earlier stage compared to women diagnosed because of complains. Including LR-HPV types in screening HPV can increase the sensitivity of the test.

Low-grade serous ovarian cancer: A review

Epithelial ovarian cancers can be divided into the more common, aggressive type II cancers and the less common, slow-growing type I cancers. Under this model, serous ovarian carcinomas can be subdivided into high-grade (type II) and low-grade (type I) tumours. The two-tier system for grading serous ovarian carcinomas is superior to more detailed grading systems in terms of predicting survival. Low-grade serous carcinomas typically present in young women and have a relatively good prognosis, despite being resistant to chemotherapy. Low-grade serous cancers have a high prevalence of KRAS and BRAF mutations, but a low prevalence of TP53 mutations (which are characteristic of high-grade serous cancers). Among women with low-grade serous ovarian cancer, the presence of a KRAS/BRAF mutation is a favorable prognostic factor. Studies of the mitogen-activated protein kinase (MAPK) inhibitor in low-grade serous ovarian cancer suggest that identifying MAPK mutations might eventually be useful in guiding treatment.

The diagnostic performance of ultrasound for acute appendicitis in pregnant and young nonpregnant women: A case-control study

BACKGROUND

Ultrasonography is frequently used to diagnose acute appendicitis in women of reproductive age, but its diagnostic value in pregnant patients remains unclear. This study sought to compare the diagnostic performance of ultrasound in pregnant and young nonpregnant women with suspected acute appendicitis.

METHODS

The database of a single tertiary medical center was reviewed for all women of reproductive age who underwent appendectomy either during pregnancy (2000-2014) or in the nonpregnant state (2004-2007) following ultrasound evaluation. The performance of ultrasound in terms of predicting the final pathologic diagnosis was compared between the pregnant and non pregnant groups using receiver operating characteristic curve analysis.

RESULTS

Of 586 young women treated for appendicitis during the study periods (92 pregnant, 494 non-pregnant), 200 underwent preoperative ultrasound [67 pregnant, and 133 nonpregnant young women]. The pregnant and nonpregnant groups were comparable in age and presenting symptoms. There was no significant difference in the predictive performance of ultrasound between the two groups (AUC 0.76 and 0.73 respectively, p = 0.78) or within the pregnant group, by trimester [first (n = 23), AUC 0.73; second (n = 32), AUC 0.67; third (n = 12), AUC 0.86; p = 0.4]. Ultrasound had a positive predictive value of 0.94 in the pregnant group and 0.91 in the nonpregnant group; corresponding negative predictive values were 0.40 and 0.43.

CONCLUSIONS

There appears to be no difference in the ability of ultrasound to predict the diagnosis of acute appendicitis between pregnant women and nonpregnant women of reproductive age. Therefore, similar preoperative imaging algorithms may be used in both patient populations.

Risk factors for endometrial cancer among women with a BRCA1 or BRCA2 mutation: a case control study

BRCA mutation carriers may use tamoxifen for breast cancer prevention or treatment. Hormone replacement therapy is often prescribed after surgical menopause and oral contraceptives are recommended for ovarian cancer prevention. The objective of this study was to assess the impact of these medications and other risk factors on endometrial cancer risk in BRCA carriers. Women with a BRCA1 or BRCA2 mutation were identified from a registry of mutation carriers. Cases were 83 women who had a diagnosis of endometrial cancer. Controls were 1027 matched women who did not develop endometrial cancer and who had an intact uterus. All women completed a baseline questionnaire, which included questions about ages at menarche and menopause, oral contraceptive use, hormone replacement therapy use, hysterectomy, oophorectomy, breast cancer history and tamoxifen use. We estimated the odds ratio associated with each risk factor in a multivariate analysis. No differences were found between cases and controls in terms of age at menarche, BMI, smoking, or oral contraceptive use. In a multivariate analysis, for women taking estrogen-only hormone replacement therapy, the odds ratio was 0.23 (95% CI 0.03-1.78, p = 0.16), and for women taking progesterone-only hormone replacement therapy the odds ratio was 6.91 (95% CI 0.99-98.1, p = 0.05). The adjusted odds ratio for endometrial cancer associated with a history of tamoxifen use was 3.50 (95% CI 1.51-8.10, p = 0.003). The observed increased risk of endometrial cancer associated with progesterone-only therapy merits further study.

Two-Dimensional Sonographic Evaluation of Endometrial Polyps - Parameters That Are Reassuring

AIMS

To assess intra-endometrial lesions according to five two-dimensional sonographic parameters for predicting malignancy.

MATERIAL AND METHODS

This is a retrospective analysis of stored digital images from consecutive pathological reports of patients with benign endometrial polyps and stage 1 endometrial carcinoma. Five sonographic parameters were evaluated: heterogeneous or complex echogenicity of the lesion, presence of a 'bright edge sign,' regular endometrial-myometrial junction, the presence of a normal endometrium adjacent to the lesion, and detection of small intralesional cysts. The sensitivity, specificity, PPV, and NPV of these parameters were calculated, as well as combinations of pairs of parameters.

RESULTS

Seventy-nine patients were eligible for the current study, 26 with benign endometrial polyps and 53 with stage 1 endometrial carcinoma. The sonographic appearance of numerous small intralesional cysts (cystic formation) was highly related to benign polyp; the presence of a lesion with heterogeneous echogenicity had sensitivity and specificity for malignancy of 63.5 and 88.5%, respectively.

CONCLUSIONS

We have shown that asymptomatic endometrial lesions, which are homogenous, have bright edges, and small intralesional cysts are likely to be benign Determining these parameters during sonographic evaluation can assist in identifying patients who will benefit from a follow-up strategy instead of an unnecessary surgical intervention.